Insurance

Administration

Rule R590-268: Small Employer Stop-Loss Insurance

Effective Date: 05/09/2023

Admin. Code Reference: R590-268

Rule Type: Current Rule

R590. Insurance, Administration.

R590-268. Small Employer Stop-Loss Insurance.

R590-268-1. Authority.

This rule is promulgated by the commissioner pursuant to Sections 31A-2-201 and 31A-43-304.

R590-268-2. Purpose and Scope.

(1) The purpose of this rule is to:

(a) provide the content of a stop-loss insurance policy disclosure;

(b) define prohibited lasering practices; and

(i) a rate and form filing and;

(ii) a report filing, including:

(A) the insurer's stop-loss experience;

(B) an actuarial certification of compliance; and

(2) This rule applies to an insurer marketing or offering a small employer stop-loss contract.

R590-268-3. Definitions.

Terms used in this rule are defined in Sections 31A-1-301 and 31A-43-102. Additional terms are defined as follows:

(1) "Qualified actuary" means an individual who is qualified to sign the applicable statement of actuarial opinion in accordance with the American Academy of Actuaries qualification standards.

(2) "SERFF" means the System for Electronic Rate and Form Filing.

R590-268-4. Stop-Loss Insurance Disclosure.

(1) An insurer offering stop-loss insurance to a small employer shall use the Utah Stop-Loss Disclosure dated July 1, 2019, available on the department's website, https://insurance.utah.gov.

(2) An insurer may display the insurer's name, identifying logo, and address on the disclosure.

(3) The disclosure may be altered upon approval of the commissioner.

R590-268-5. Lasering.

The following lasering practices are prohibited under Section 31A-43-301:

(1) assigning a different attachment point for an individual based on the individual's expected claims or a given diagnosis;

(2) assigning a deductible to an individual that must be met before stop-loss coverage applies;

(3) denying stop-loss coverage to an individual who is otherwise covered by the small employer's health plan; and

(4) applying an actively at work exclusion to stop-loss coverage.

R590-268-6. Form and Rate Filings.

(1) An insurer shall file a stop-loss insurance contract and application with:

(a) any related documents;

(b) if altered, a disclosure as outlined in Section R590-268-4; and

(2) A new or a revised rate filing shall:

(a) include:

(i) a summary of the rate calculation;

(ii) geographic rating area factors applicable in Utah;

(iii) a description of how the overall rate is compliant; and

(iv) an actuarial certification signed by a qualified actuary; and

(b) be filed no later than 30 days before use.

(3) A stop-loss contract shall be consistently applied to each small employer.

(4) A filing shall be submitted using SERFF.

R590-268-7. Annual Certification.

(1) An insurer shall, on or before April 1, submit the following using SERFF:

(a) stop-loss experience as described in Subsections (2) and (3) for the previous two years;

(b) an actuarial certification of compliance with Title 31A, Chapter 43, Small Employer Stop-Loss Insurance Act; and

(2)(a) An insurer's stop-loss experience shall be presented by:

(i) small employer; and

(ii) experience year.

(b) An insurer's stop-loss experience shall include:

(i) a group identifier that uniquely identifies the employer group and is consistent from year to year for the same employer group;

(ii) the effective date of coverage for each policy year;

(iii) the contract term;

(iv) the employer size, including number of covered lives and employees, at the beginning of the contract;

(v) the number of covered lives and employee exposure years for the period of the experience;

(vi) the specific attachment point;

(vii) expected claims absent stop-loss insurance;

(viii) expected claims under the specific attachment point;

(ix) the aggregate attachment point;

(x) earned premium; and

(xi) claims paid by the stop-loss insurance separated by specific losses and aggregate losses.

(i) be aggregated over the entire contract period, rather than aggregated by month; and

(ii) only include stop-loss contracts where the final claim date is contained within the two calendar years before the submission date.

(d) Runout claims that are paid after the submission date shall be updated in the following years' experience submission.

(3) An insurer's stop-loss experience shall be submitted using the Utah Stop-Loss Experience Report dated July 1, 2019, available on the department's website, https://insurance.utah.gov.

R590-268-8. Severability.

If any provision of this rule, Rule R590-268, or its application to any person or situation is held invalid, such invalidity does not affect any other provision or application of this rule that can be given effect without the invalid provision or application. The remainder of this rule shall be given effect without the invalid provision or application.

KEY: small employer stop-loss

Date of Last Change: May 9, 2023

Notice of Continuation: March 7, 2024

Authorizing, and Implemented or Interpreted Law: 31A-43-304; Title 31A, Chapter 43